APPENDIX 10-1

EXAMPLES OF OCCUPATIONAL HEALTH DELIVERY SYSTEMS

Here are three examples of OHDSs at large, medium, and small workplaces. The first is a manufacturing firm with about 1,500 employees in two locations. The second is a meatpacking company employing about 500. The third example is a small, independent janitorial service with 35 employees. These examples show that each company's service needs are individual and that their methods for providing the services differ. An important point demonstrated is that sometimes services are best provided by people whom you hire as your own employees; in other situations, it may be better to contract for these services. In our examples, notice that sometimes employers use community agencies to supply services. Using community agencies may save you money.

BACKGROUND INFORMATION ON THE SAMPLE COMPANIES

Example 1. Of the workers employed by the larger manufacturing company, 1,000 are at one site where the components of their major product are manufactured. A second site 5 miles away has 500 employees in two buildings. One houses a line where the components are assembled, as well as the facility's maintenance department and a garage where the company trucks and other vehicles are parked and serviced. The other building at the second site contains executive offices for all the administrative divisions, such as accounting, human resources, and marketing, plus a small showroom.

The manufacturing site is 17 miles from the nearest medical facility. The light assembly and administrative site is 12 miles from the nearest medical facility. The company runs two shifts, each 8 hours. These are a day shift and an evening shift. There are two security personnel working alone from midnight to 7 a.m.

Company One employees a safety professional to head its safety department and an occupational health nurse practitioner to head its OHDS. Both departments have other professional and non-professional staff to support the department heads. The safety department and OHDS both have offices at the manufacturing site.

Example 2. Company Two, the meatpacking company that employees 500 workers, has 460 people working in the slaughter department and the department where carcasses are dismantled. These divisions operate on a day shift of 10 hours. In addition, there are 20 people who perform plant sanitation and maintenance functions on an overlapping evening shift. Another 20 employees are in supervisory positions and in administrative positions such as personnel, payroll, and safety and health.

The plant is 7 miles from the nearest health care facility. The company employs a full-time occupational health nurse (registered nurse) and a full-time safety director.

Example 3. Company Three, the small, independent janitorial service, provides cleaning and light maintenance services for commercial buildings. There are 35 employees: the owner-manager, three clerical support personnel, an evening supervisor, and 30 service personnel, 20 men and 10 women. The service personnel report to a central office from which they are dispatched in teams of two or three in company vans. The service personnel all work an evening shift from 5 p.m. to 1:30 a.m. Two of the clerical employees work a day shift, 9 a.m. to 5:30 p.m. One clerical employee works a shift that spans the day and evening shifts. The supervisor works the same evening shift as the service personnel.

No safety, industrial hygiene, or occupational health professionals are employed by this company.

In the sections below you will find major portions of an OHDS and descriptions of how our three sample workplaces handle these tasks.

HAZARD ANALYSIS

At Company One, the basic work of providing a comprehensive assessment of hazards (see Chapter VII) was done by a committee composed of the safety director, the occupational health nurse practitioner, the director of manufacturing, the supervisor of maintenance, and two line employees, one from the day shift and one from the evening shift. In addition, a consultation was requested from the liability insurance company's loss control division. The consultation was conducted by an industrial hygienist who confirmed the need to monitor for noise in the manufacturing area. She also helped the occupational health nurse practitioner and the human resources director write job descriptions for the major employee classifications. The descriptions emphasized important safety and health considerations such as the amount of weight lifted and the chemicals handled.

A second consultation was obtained from the department of occupational medicine at the nearby university. The occupational medicine physician suggested a design for a health surveillance program for cumulative trauma disorders (CTDs) in the shoulders, arms, and hands of the employees in light assembly. The program is designed to use personnel and other resources already available at the company.

At Company Two, the meatpacking company's safety and health committee consisted of the safety director, the occupational health nurse, a supervisor, and four hourly employees, one each from the slaughter, fabrication, sanitation, and maintenance departments. This group's hazard assessment included basic safety and industrial hygiene evaluations as well as a complete ergonomic review following the "OSHA Ergonomic Program Management Guidelines for Meat Packing Plants," OSHA Publication 3123 (Revised 1993). Their assessment included a check for potential exposures to communicable diseases from the slaughtered animals. The committee developed a list of questions about safety and health conditions and potential hazards in the plant. To answer these questions, the committee performed a series of walk-throughs and employee interviews.

In addition, the safety director and the occupational health nurse analyzed the actual jobs being performed by line employees for potential ergonomic problems. OSHA's ergonomic guidelines helped them identify those positions that involved the specific activities associated with the development of CTDs. Furthermore, they reviewed all of the material safety data sheets (MSDSs) for all the chemicals used for cooling and sanitation at the plant.

At Company Three, the owner-manager of the janitorial service was aware, from reading the newspaper, that OSHA was enforcing protective measures for workers exposed to ergonomic hazards. She contacted the OSHA-funded, State-run consultation service and received information about the criteria that were being used for enforcement. This information guided her in organizing a management system that would meet the enforcement requirements. At the owner's request, consultation personnel examined this system and other aspects of the company's safety and health program, including the hazards to which employees were exposed. They helped develop protection against the hazards found and recommended a CTD training program with an emphasis on back injuries. They also recommended a driver safety program.

EMPLOYEE TRAINING

At Company One, the safety director and the occupational health nurse practitioner designed training programs to be delivered during employee orientation. The programs inform the employees about the company safety and health policies and program, and alert them to the specific hazards in their jobs and what they need to do to protect themselves. The training is conducted by safety department and OHDS staff members who have prepared by taking special train-the-trainer courses. Employees are invited to contact the safety director, the occupational health nurse practitioner, or their supervisors if they have further questions. The training includes a short test at the end to demonstrate that the employees understand their specific risks and how to protect themselves. There is a regular schedule for follow-up training.

Because the plants of Company One are more than 10 minutes away from the nearest medical facility, the decision was made to establish emergency response teams in both locations and on both shifts. The teams are set up on a volunteer basis and consist of five employees per shift per location plus all the security personnel. The company contracts with the American Red Cross to provide training and refresher classes in first aid and cardiopulmonary resuscitation (CPR) at the workplace.

Because emergency response team members in the course of their duties could be exposed to infectious diseases such as hepatitis B and AIDS, they are covered by OSHA's Bloodborne Pathogens standard. Consequently, in addition to the training required by the standard, they also have been offered the hepatitis B vaccine (but see footnote), and personal protective equipment to protect them against exposure has been selected and distributed to them by the occupational health nurse practitioner.

Management in Company Two decided to conduct the employee training program using their own company personnel. The safety director designed the training to address hazards such as fire, walking surfaces, cuts, elevations, and ammonia leaks. The occupational health nurse designed training that promotes hygienic practices to reduce the possibility of exposure to biologic hazards such as brucellosis, anthrax, and Q fever associated with animal handling. In many respects, the activities performed by the workers to protect the meat from contamination, as required by the U.S. Department of Agriculture, also protect them. Where this is not the case, the program is designed to emphasize what employees need to know and do to protect themselves. The nurse also developed material that informs the employees about the early signs and symptoms of CTDs and ways to help prevent them.

Together, the occupational health nurse and the safety director at the meatpacking company instruct the employees about the chemical and temperature hazards associated with the industry. Additional classes are held for the clerical, sanitation, and maintenance workers. In addition, supervisors are trained to recognize the early symptoms of ergonomic problems, so that they can encourage workers to report these problems as readily as other injuries or illnesses.

Five volunteers from each plant area or unit and all the supervisors from each shift make up the company's emergency response team. A commitment of 1 year is expected of members of the team. These employees are covered by OSHA's Bloodborne Pathogens standard (but see footnote). They all were given first aid training that included instruction and practice in how to protect themselves from exposure to bloodborne pathogens such as the hepatitis B and AIDS viruses. Retraining occurs for all team members at the anniversary date, when new members are added.

At Company Three, the State OSHA consultation office suggested contracting with a nearby occupational health clinic, already providing work-related employee health services, to conduct training in the prevention of CTDs with an emphasis on back safety. In addition, the employees are informed about the contents of the cleaning solutions they are using along with proper mixing techniques and the use of gloves and protective eye glasses. The MSDSs, which list toxic ingredients, are explained, and employees are told where these documents are kept.

The initial class was provided at the janitorial service company's central office. Since then, new employees are instructed at the clinic as part of their pre-placement physical examination and orientation. Finally, the owner received booklets promoting safe defensive driving and the use of seat belts from the Automotive Occupant Restraint Council. These booklets were distributed to all current employees and are included in the orientation materials for all new employees. The employer plans to develop and distribute to all employees a brief self-test based on the booklet.

The employer encourages the service personnel to take a beginning first aid course offered through a local municipal adult education program by granting paid time for the class. The evening supervisor was required to take the beginning and advanced first aid course.  Each van is supplied with a first aid kit, as is the office. The service employees are instructed to report all injuries and illnesses to the supervisor at the end of their shift, or sooner by phone if they think that the problem needs more than minor first aid treatment. The supervisor then refers the employee to a nearby emergency room or the contract occupational health clinic as necessary.

HEALTH SURVEILLANCE

In Company One, machines in two departments were extremely noisy. The safety director designed, and the maintenance department constructed, double layered sheet rock walls with sound reducing baffles between them around the two machines. Then the company contracted with an industrial hygienist to perform an environmental sound survey. This survey showed that, even after construction of the sound baffles, the noise level in one of the departments was still too high. The company also contracted with a nearby audiologist to perform baseline pure tone hearing tests on all current employees. New employees for the department designated as too noisy are tested as part of their orientation. The required annual audiometric testing is done by this same audiologist. The occupational health nurse practitioner conducts the education program about hearing conservation. She also did the research necessary in order to purchase the best hearing protectors for the employees.

Company Two consulted with the occupational medicine physician to develop a CTD surveillance program. As one result, the physician made the portion of the pre-placement physical examination that dealt with the upper extremities and the back more detailed for the workers in the slaughter department and the division where carcasses are dismantled. At the 6-month and 1-year anniversary dates, randomly selected employees are invited back to be reexamined. Examination results that indicate early development of CTD are reported to the employees, and management is informed about which positions need further evaluation. However, no personal information that identifies particular employees is released to management.

Company Three had no need of health surveillance.

ANALYSIS OF EMPLOYEE USE OF THE OHDS.

Company One. At Company One, a clerk in the OHDS office is assigned to enter information about each employee visit onto a spread sheet that includes the date, the time of day, the employee's department, the employee's complaint, and the treatment rendered. Totals from the graph are examined by the occupational health nurse practitioner every month. Any unusual clusters of complaints are investigated by the safety committee.

At Company Two, the occupational health nurse maintains a spread sheet of all employee visits to the health office. She combines this information with that received from the contract occupational medicine physician to form a report that is presented to the safety and health committee each month. This report and the accident reports become the basis for special safety and health emphasis programs within the company.

For Company Three, the contract occupational health clinic sends a monthly statement to the employer that summarizes all bills that have been submitted to the company's workers' compensation insurance carrier. This summary includes both diagnostic and treatment information. The employer analyzes this information for trends in injuries and illnesses as one way of determining if employees are being exposed to identified hazards, if hazards exist that have not been identified, or if employees need more training about hazards.

ESTABLISHING STANDARD PROCEDURES

For Company One, the occupational health nurse wrote procedures for the "first aiders" to use when administering first aid, CPR, and emergency transfer of ill or injured workers. She also wrote procedures that describe the standardized assessment and onsite treatment that she uses for employee illnesses or injuries and for all health surveillance programs.

At Company Two, the occupational health nurse and the contract occupational medicine physician worked together to write procedures for all the treatment given in the OHDS office, including the dispensing of over-the-counter medications. They also wrote procedures for hygienic practices for the employees exposed to biologic hazards. These procedures were intended to ensure that employees do not consume food, beverages, and tobacco products with contaminated hands, and that they do not accidentally contaminate their street clothes or shoes before leaving the plant. The safety director and the occupational health nurse developed procedures for ensuring that the employees of contractors performing pest eradication operations do not accidentally expose employees to pesticides. Finally, this same team developed procedures that included proper work techniques and frequent knife sharpening to prevent ergonomic problems.

For Company Three, the State OSHA consultation staff worked with the owner to develop standardized procedures for first aid and emergency situations. They also wrote specific procedures for mixing and using all the cleaning solutions, using the buddy system for lifting heavy objects, and rotating tasks involving lengthy repetitive motions such as vacuuming. Discussion of the procedures is included in the new employee orientation.

EARLY RECOGNITION AND TREATMENT

At Company One, the occupational health nurse practitioner who heads this department has graduate level training in assessment and management of occupational illnesses and injuries. She is licensed to treat many of the employees' occupational injuries and illnesses using previously approved standard procedures. A referral relationship has been established by contract with a local hospital that has an emergency room and an occupational medicine clinic. Employees with illnesses or injuries that are assessed by the nurse practitioner as too severe to be treated onsite are transferred to the emergency room. Those employees who are receiving treatment by the nurse practitioner and do not respond as expected are referred to the occupational medicine clinic. In this way, a majority of the company's work-related injuries and illnesses are treated within the OHDS.

Company Two has a policy that encourages employees to promptly report symptoms of illness and injuries to the occupational health nurse. The nurse treats minor illnesses and injuries in the plant health office using dressings, ice, and over-the-counter medications. She refers more severe problems to the contract physician. This nurse has taken a continuing education course in the recognition and conservative treatment of CTDs and is able to implement early treatment and referral. She also is able to review preventive measures with the employees at each visit.

At Company Three, the contract clinic's medical director has completed a mini-residency in occupational medicine and has ample knowledge of the risks to which this company's workers could be exposed.

MEDICAL CASE MANAGEMENT

At Company One, the occupational health nurse practitioner works with the personnel manager to develop a case management system for all employees who are off work with illnesses or injuries lasting more than 5 days. The system consists of a method for prompt treatment authorization, a referral list for second opinions, assistance in filling out insurance forms, communication with the insurance carrier to ensure timely benefit payments, and ongoing contact with the employee and the family.

At Company Two, the occupational health nurse and the contract occupational medicine physician maintain close communication about all employees with work-related injuries and illnesses that are not responding to treatment as expected. The occupational health nurse ensures that specialist referrals occur promptly. The nurse practitioner also works closely with the supervisors, proposes modified duty positions, and clears these work proposals with the treating physician. This facilitates employees' returning to work as soon as possible.

At Company Three, the owner functions as the human resources director as well as the manager. As such, she is in close contact with any employee who experiences lost worktime related to industrial injury or illness. She does not, however, have access to her employees' individual medical records, which are maintained confidentially at the contract occupational health clinic. She considers this adequate case management. Her workers' compensation insurance carrier assists her by providing information about helping injured and ill workers return to work quickly. The suggestions have prompted her to increase the frequency with which she makes telephone contact with these employees.

COORDINATION FOR EMERGENCY SERVICES

At Company One, the safety director, the occupational health nurse practitioner, and the head of the security department worked together to develop a system whereby all employees in each department know their exact responsibilities in the event of an emergency. They also discussed their plan with the local fire department that will be responding to emergency calls.

At Company Two, the occupational health nurse practitioner and the safety director head the team and respond to each emergency. The plant receptionist is responsible for contacting outside emergency organizations, so this person is included in the emergency response team meetings.

At Company Three, because employees move from one workplace to another instead of having a fixed worksite, no special arrangements were made with emergency organizations. The company, however, did make its own emergency preparations (discussed under "Employee Training.")

RECORDKEEPING

At Company One, the OSHA 200 Log, the MSDSs, and the results from the noise surveillance are maintained in the OHDS office, where the occupational health nurse practitioner can answer employee questions. All employee visits to the OHDS office are documented in the individual employee medical record.

At Company Two, the OSHA 200 Log, the MSDSs, and the results from the CTD surveillance are kept in the OHDS office, where the occupational health nurse can answer employee questions. All employee visits to the OHDS office are documented in the individual employee medical record.

At Company Three, the OSHA 200 Log and the MSDSs are maintained by the owner and are available for the employees to see upon request. Individual employee medical records are kept at the contract occupational health clinic and remain confidential.

(For more detailed information about recordkeeping, see Appendix 10-2.)

SUMMARY

The examples demonstrate how three different employers provide OHDS services using a combination of in-house resources, sub-contractors, and government agencies. Some of the sub-contractors bring their services to the premises, while in other situations the employees travel to the contractor. In each case, the employer has selected services based on the special characteristics of the business process, the potential exposures within that process, the business location, and the employee population.

Each OHDS includes activities aimed at the prevention of exposures, the early recognition and treatment of work-related illnesses and injuries, and a reduction in the severity of and potential for disability from work-related illness and injury.